Impacts at individual and household level: Inequities in coverage and access to health care
Universal Health Protection 25
Figure 3.17. Coping with health care expenditure through selling assets and borrowing, by household income level, selected African countries
Source: Leive and Xu, 2008.
Among the most important causes of OOP are limitations of benefit packages and low quality of services covered, resulting in health services and goods that are not financially
protected but instead have to be paid for directly to the service provider by the individual.
An example of limitations in benefit packages relates to pharmaceutical drugs, i.e. medicines that are only available on written prescription from a doctor, dentist or
pharmacist. In low- and middle-income countries, prescription drugs represent one of the most significant components of health-related OOP, accounting for 26 to 63 per cent of the
total and often caused by exclusion from benefit packages. This is one of the most important reasons for catastrophic health expenditure see for example Wirtz et al., 2012
on Mexico.
Figure 3.18 shows the percentage of health expenditure for pharmaceutical drugs by households in four developing countries. While in Bangladesh it amounts to 70 per cent of
household health expenditure, it exceeds 88 per cent of health expenditure for Vietnamese households. Poorer households not only spend proportionally more on medicaments
because of their lower incomes, but are frequently also paying the highest OOP for them in absolute terms, due to the fact that the public sector in developing countries is often unable
to provide affordable medicaments in a reliable way UNDP, 2005.
10 20
30 40
50 60
70 80
Burkina Faso Congo
Ethiopia Kenya
Mali Namibia
Zambia
Percent of households selling assets or borrowing to finance health payments by income quintile
Lowest Quintile 2
Quintile 3 Quintile 4
Highest
26 Universal Health Protection
Figure 3.18. Expenditures on pharmaceutical drugs as a percentage of households’ health expenditures in four developing countries, 2003
Source: Wirtz et al., 2012.
The magnitude of the burden of OOP for medicaments, as well as its heavier weight on the poor in relative terms, can also be illustrated using findings from Brazil table 3.1. On
average, OOP account for 60.6 per cent of family OOP for health care in the wealthiest income decile, but up to 82.5 per cent in the poorest decile.
Table 3.1. Brazil: Distribution of direct family per capita OOP for health care, by income decile, 2007
percentages
Family per capita income decile from lowest to highest Health spending item
1 2
3 4
5 6
7 8
Medicaments 82.5
73.4 72.4
72.1 67.6
65.8 62.9
60.6 Dental treatment
2.2 5.4
7.3 6.7
8.6 8.8
12.3 14.4
Physician appointments 5.3
6.5 6.2
6.2 7.3
8.3 7.8
8.5 Out-patient treatment
0.5 0.7
0.7 0.5
1.2 0.8
0.8 0.9
Hospitalization surgical services 0.5
1.4 2.1
3.3 3.4
3.9 4.4
2.5 Other
9.1 12.6
11.3 11.2
12 12.3
12.1 13
Source: Dominguez Ugá and Soares Santos, 2007.
The catastrophic impact of OOP for medicaments on households is further revealed in terms of work needed to generate sufficient income to afford them. Figure 3.19 shows the
number of day wages needed to purchase respiratory infection medicaments in six countries, using the average wage of the lowest-paid government officials as a reference.
As such officials are not usually in the category “poor”, the figure shows that medicaments − especially those of highest quality, i.e. originator brand − can become unaffordable for
the lowest income groups.
75 70
80 88
10 20
30 40
50 60
70 80
90 100
India Bangladesh
Burkina Faso Vietnam
Universal Health Protection 27
Figure 3.19. Affordability of medicaments: Number of day wages needed to purchase respiratory infection medicine Ciprofoxacin
Note: Lowest-paid government worker’s wage is used as reference. Source: WHO, 2011a.
Geographic inequities The principle of universality of social protection provisions implies that geographic
location should not play a role in access to health care for those in need ILO Recommendation No. 202, para. I. 3a. Nevertheless, significant geographic inequities
persist in access to health care, mainly related to gaps in availability. In many countries health-care facilities tend to be concentrated in urban areas, resulting in higher barriers to
access for those living in rural areas figure 3.20.
Figure 3.20. Global rural population with legal health coverage percentages
Source: Scheil-Adlung, 2013a.
Barriers in access to health care for rural dwellers become obvious when analysing the urbanrural differences in coverage and utilization rates of health care. At the global level,
the percentage of the population covered is negatively correlated with the extent of the rural population. While coverage rates exceed 85 per cent of the population living in
countries where less than 25 per cent are living in rural areas, only 15.6 per cent are covered in countries where rural populations exceed 70 per cent Scheil-Adlung, 2013a.
2 4
6 8
10 12
14 16
18 Philippines
Indonesia Nigeria
Jordan El Salvador
Morocco
Lowest-priced genetic Originator brand
85.8 76.0
69.7
29.2 15.6
0.0 20.0
40.0 60.0
80.0 100.0
Health care coverage: global average
Less than 25 25-49
50-69 50-69 excluding China
70 and over
28 Universal Health Protection
In addition to, which refers to rights and entitlements, place of residence is often an explanation for gaps in effective access to health care. In general, infrastructure and
availability of health professionals act as indicators of effective access. In Ghana, for instance, 25 per cent of the population live over 60 kilometres away from a health facility
attended by a doctor Salisu and Prince, 2008. In the United Republic of Tanzania, long distances to health facilities with adequate staffing deprive those in need of care: the main
reason why 44 per cent of women are unable to give birth in a health facility is that they live too far away from an adequate facility to reach it in time Perkins et al., 2009.
A survey in Cambodia illustrated that place of residence has a significant impact on the choice of whether or not a person will seek medical treatment figure 3.21. Of those who
were ill or injured in the 30 days before they became a respondent to the Demographic and Health Survey DHS, only 6 per cent in urban areas did not seek care, while in rural areas
the number was twice as high. The number of persons not seeking a second or third treatment was also significantly higher for rural dwellers.
Figure 3.21. Cambodia: Urban and rural household members not seeking treatment, 2005 percentages
Note: Ill or injured in the 30 days preceding the Demographic and Health Survey. Source: DHS Cambodia, 2005.
In turn, within urban regions certain subgroups are at least as deprived of access to adequate health-care services as their rural counterparts. This is largely due to rapid
urbanization resulting in an increasing number of rural-to-urban migrants living in slums, where access to basic services such as sanitation, education and health care is very limited.
These urban poor often fare worse than rural dwellers with regard to access to such services.
Table 3.2 shows that in Bangladesh, 21 per cent fewer births in urban slums are assisted by a skilled birth attendant than in rural areas, indicating lower availability and quality of
health workers. As a result, the under-5 mortality rate U5MR is 44 per cent higher in slums UNICEF, 2010.
Table 3.2. Bangladesh: Birth assistance and under-5 mortality rates, urbanruralslum populations, 2010
Indicator Urban
Rural Slums
Slum worse than rural
Skilled attendance at birth 45
19 15
-21 U5MR per 1,000 live births
53 66
95 44
Source: UNICEF, 2010
93 90
79 74
12 6
10 20
30 40
50 60
70 80
90 100
Rural Urban
Rural Urban
Rural Urban
T h
ir d
tr e
a tm
e n
t Se
co n
d tr
e a
tm e
n t
Fi rs
t tr
e a
tm e
n t
Universal Health Protection 29
10 20
30 40
50 60
70 80
90 100
10 20
30 40
50 60
70 80
90 100
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
R u
ra l
U rb
a n
Madagascar Nicaragua
South Africa Morocco
El SalvadorEcuador
Paraguay Egypt
Bolivia Indonesia
Panama Viet Nam
Mexico Peru
Serbia Uruguay
E xt
e n
t o
f so
ci a
l h e
a lt
h p
ro te
ct io
n a
s a
p e
rc e
n ta
g e
o f
to ta
l p o
p u
la ti
o n
Male Female
Gender-related inequities In addition to geographical inequities, inequities in access for men and women can be
observed in many countries, as shown in figure 3.22.
Figure 3.22. Legal health coverage as a percentage of total population, by sex and area of residence, selected countries, latest available year
Source: ILO, 2013a.
In most countries there is lower coverage for women than for men, with the most significant difference being found in Egypt.
Millennium Development Goal MDG No. 5, which focuses on improving maternal health, has been reported as the most off-track of all MDGs. In 2010, 287,000 maternal
deaths occurred globally, corresponding to a 47 per cent decline in maternal mortality since 1990. Sub-Saharan Africa and South Asia accounted for 85 per cent of these deaths
UNFPA, 2012. Many of these countries are unlikely to reach the first target of MDG 5 of reducing maternal mortality rates by 75 per cent by 2015. The maternal mortality ratio in
developing regions has decreased since 1990 from 440 maternal deaths per 100,000 live births to 240 in 2010 UNDP, 2013b. Nevertheless, this ratio remains 15 times higher than
in developed countries.
In addition to improving maternal health, MDG 5 aims at universal access to reproductive health. Globally, between 2000 and 2010 78 per cent of pregnant women received
antenatal care once during pregnancy, but only 53 per cent received the minimum of four visits as recommended by the World Health Organization WHO, 2011b. The lack of
antenatal and delivery care is almost completely concentrated among the poor. A study of 65 countries demonstrated that over 85 per cent of the wealthiest quintile of the population
use antenatal and delivery assistance, but only 55 and 22 per cent of the poorest population have access to antenatal and delivery care respectively Houweling et al., 2007. Moreover,
the few facilities offering these treatments tend to be concentrated in better-off urban areas, while many of the poor live in rural areas or slums.
30 Universal Health Protection
Since 1990, the proportion of births in the world attended by a skilled health professional has increased from 55 to 78 per cent in 2011. The regions with the lowest proportion of
births attended by a skilled health professional also have the highest maternal mortality, as can be seen in figure 3.23.
Figure 3.23. Births attended by skilled health personnel 2011 and maternal mortality ratio per 100,000 live births 2010, by region percentages
Source: ILO, based on WHO Global Health Observatory, 2013.
Further, access to maternity leave and related cash benefits provided to women working in the formal economy vary significantly between different regions figure 3.24. Only 37 per
cent of female workers in Africa receive paid maternity leave at 100 per cent of last earnings, as compared to 52 per cent of female workers in developed economies and 82 per
cent in the Middle East.
Figure 3.24. Maternity: Cash benefits and duration of leave, by region 152 countries, 2009 percentages
Source: ILO, 2010b.
82 19
52 82
13 37
19 26
18 4
2
81 22
83 61
20 40
60 80
100 Middle East
Latin America and Carribean Developed economies and EU
Central and South-Eastern Europe non-EU Asia and Pacific
Africa
Unpaid, paid less than 23 of earnings for 14 weeks, or paid for a period less than 14 weeks Paid at least 23 of earnings but less than 100 for at least 14 weeks
Paid at least 14 weeks at 100 of earnings
Universal Health Protection 31
Moreover, the scope of maternal benefits appears to be severely limited for many women. In the Republic of Moldova, for instance, more than 50 per cent of women who received
antenatal care did not receive any reimbursement for the expenses incurred; only 20 per cent received full reimbursement either by an insurance scheme or the Government ILO,
TRAVAIL database, 2011.
Age-related inequities Since 1950, the number of people aged over 60 has increased rapidly in all regions of the
world, resulting in a global increase in life expectancy by 2.7 years in 1950−55 to 4.5 years in 2005−10 UNDESA, 2012. Reductions in mortality have resulted from improved
agriculture that has increased food quantity; knowledge of disease transmission; and effective public health interventions that have controlled communicable diseases such as
malaria Jack and Lewis, 2009. Life expectancy is also substantially higher among females than among males.
These demographic changes are resulting in a rapid ageing of populations around the world, leading to increasing global demand for health care for the elderly – particularly
women in the view of their higher life expectancy. Public expenditures on health care for the elderly are consequently growing at a rapid pace, putting public budgets increasingly
under pressure. Projections forecast that life expectancy will continue to rise, accompanied by further rises in health expenditure for this age group UNDESA, 2012.
Although the economic impacts of ageing and the related shares of total health expenditure have been analysed in depth, the socio-economic consequences of gaps in health protection
of elderly households have not been in focus. The fact that older persons are more likely to experience health shocks, cost-intensive chronic illness, and frequently functional
impairments compared to their younger counterparts may result in a significant monetary burden Scheil-Adlung and Bonan, 2012.
Among the elderly, the oldest age groups are challenged by the highest OOP. Figure 3.25 shows that in many European countries individual OOP for health care increases with age.
Although expenditure shares vary between different countries, persons aged 80+ spend a significantly larger share of their household per capita income on OOP for health care than
younger cohorts in almost all selected countries.
32 Universal Health Protection
Figure 3.25. Out-of-pocket payments OOP as a share of household per capita income, by age cohort, selected European countries, 2004 percentages
Source: Scheil-Adlung and Bonan, 2012.
Poor elderly households are the most heavily affected by OOP for health care in the countries selected for figure 3.26. Although absolute OOP expenditures are often higher
for higher income quintiles, they constitute a much larger part of household income for the lowest income quintiles. In most countries the main part of OOP health expenditure among
the elderly is constituted of either costs for prescribed medicines or out-patient care. In Belgium and Spain, pharmaceutical drug expenses make up over 50 per cent of total OOP,
whereas in Greece it is out-patient care that accounts for almost 50 per cent ibid..
Figure 3.26. Elderly household OOP for different health-care items as a share of household income, by household income quintile, selected European countries, 2004 percentages
Source: Scheil-Adlung and Bonan, 2012.
In addition to the need for health care, many of the elderly have an increasing need for long-term care LTC. In spite of this, the scope of covered benefits for LTC is frequently
limited WHO, 2007. Constraints result from extremely high cost-sharing rates and
Universal Health Protection 33
missing interfaces between social and medical services in countries such as Austria, Canada, Finland, Germany, Republic of Korea, Portugal and Spain OECD, 2011.
Inequities for workers in the informal economy, migrants and ethnic minorities
Health coverage and access to care remain comparatively limited for workers in the informal economy, migrants and ethnic minorities. A variety of underlying causes are
responsible for the coverage and access gaps experienced by these groups: for example, minorities such as Roma. Besides discrimination, a lack of coverage such as in health
insurance, lack of documentation providing access to national health systems, geographic isolation from quality care, as well as other obstacles frequently deprive Roma from access
to necessary care Földes and Covaci, 2012.
While documented migrants are usually covered under national regulations, this is not the case for undocumented migrants or workers in the informal economy. They can hardly
effectively access needed care without revealing their identity and providing official papers Stanciole and Huber, 2009.
Figure 3.27 provides an overview of gaps in legal coverage and access of Roma and migrants in the European region:
Eleven per cent of Roma women were denied access to treatment due to documents lacking.
In Bulgaria and Romania 46 and 37 per cent respectively of Roma lack health insurance.
Informal-economy workers and migrants frequently experience similar barriers to necessary health care due to exclusion through financial barriers and formal rules,
including the need to provide formal documentation.
Figure 3.27. Europe: Gaps in legal coverage of Roma and migrants
Roma Migrants
European region
11 of Roma women were denied access due to lack of documents
United Kingdom
47 of all migrants are without coverage in standard employment-
based social health protection
Bulgaria 46 of Roma have no health
insurance Deficits in legal
coverage often due to
Financial barriers 30 of Roma women over
the age of 15 have no insurance Gaps in adequate services
Excluded from access by formal rules
Romania 37 of Roma have no
insurance Missing or incomplete documents
Source: EDIS SA, 2009; Krumova and Ilieva, 2008; European Roma Rights Center, 2006.